1. Cardiometabolic Health Check
Date: ……/….../……… Location: …………………………………..…
Lifestyle and Medical History
Are you diabetic? Y / N Are you taking cholesterol tablets (statins) Y / N
Are your parents or siblings diabetic? Y / N Has a parent or sibling under 55
Are you taking blood pressure medicine? Y / N ever had a heart attack? Y / N
Your details:
First name: ……………………………………
Surname: …………..…………………
Date of Birth: ……/….../………
Ethnicity: ……………………………..
Smoking
Non smoker o Ex-smoker o (year quit…………..)
Current smoker o Cigarettes per day ….… Years smoking……..
Gender: M / F
Address: ………………………………………………………………………………………….
……………………………………………………………………………………………...
Post Code: ……………………..
Alcohol
Units per week …………….
GP Details:
Doctors name: ……………………………………………………………..
Practice address: ……………………………………………………………………………..
……………………………………………………………………………….………………………..
Test results
Height ………..cm
Weight ………..kg (…….st …….lb)
Body Mass Index (BMI) ………….
Blood pressure ………../………..
Test results measured on (device)
HbA1c ……….. mmol/mol ………………………………
Total cholesterol ……….. mmol/L ………………………………
HDL cholesterol ……….. mmol/L ………………………………
Total cholesterol:HDL ratio ……….
Random glucose ……….
Consent
I agree to having the tests below measured on me and for them to be forwarded to your GP. The results are confidential but anonymised results may be used for research purposes and publication.
Patients signature: ………………………………………………………………………………………..
QRISK risk:
Your risk of having a heart attack or stroke within the next 10 years is: …………….%